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What You Eat Does Matter

LifelineLetter, September/October 2008

Laura
Matarese, PhD, RD, LDN, FADA, CNSD

We eat both for the
nutrients food provides and for the pleasure of eating. But if you have short
bowel syndrome (SBS), the type of food you eat and the way you consume foods are
especially important, as these factors will affect your absorption. This article
will review the types of foods you should consume and the way you should consume
them if you have SBS.

Short
Bowel Syndrome

What exactly is SBS? And
what do we mean by “short”? The normal small bowel length in adults ranges from
300 to 800 cm. Loss of two-thirds or more of the small bowel is defined as SBS.
However, as many of you know, it is not just the length that matters, but how
well the remaining bowel functions. So you may not have much bowel, but what you
have works pretty well. Or you may have plenty of bowel, but it is diseased and
doesn’t function optimally.

Diet

Dietary modification is
the foundation of therapy for someone with SBS. This is one area where you, the
home parenteral and/or enteral (homePEN) consumer, have total control. You can
decide what you eat, how much, and when. Making small adjustments in your diet
will help you manage your ostomy output or bowel movements. This, in turn, may
allow you to reduce your dependence on parenteral nutrition (PN).

GI
Anatomy

Let’s start with a few
basic concepts. Your diet must be based on your own gastrointestinal anatomy. If
you have SBS and your colon is in circuit, you will maximize your absorption if
you follow a diet that is low in simple carbohydrates and low in fat. If you
have SBS and a jejunostomy, there is no need to restrict fat, but limiting the
simple carbohydrates will help to decrease the ostomy output.

Carbohydrates

What is a simple
carbohydrate and what is a complex carbohydrate? A simple carbohydrate consists
of two sugar molecules that are hooked together to form a disaccharide. Examples
of these are sucrose (table sugar) and lactose (milk sugar). These are found in
foods such as candy, cakes, cookies, pies, regular soda pop, jelly, jam, syrup,
ice cream, sherbet, and sorbet. If you have SBS and you consume large amounts of
these simple carbohydrates, you may experience more diarrhea.

Complex carbohydrates are
composed of large starch molecules. When consumed, complex carbohydrates
generally do not produce a lot of diarrhea. Complex carbohydrates are found in
pasta, potatoes, breads, cereals, whole grains, fruits, and vegetables.

It might be tempting to
consume foods that are “low carb.” However, these foods often contain sugar
alcohols such as sorbitol and manitol instead of sugar. Sugar alcohols are not
absorbed by the gastrointestinal tract. They tend to cause diarrhea and foods
containing these “sweeteners” should be avoided. You may find these sugar
alcohols in sugar-free mints and chewing gum, as well as in diabetic candies and
cookies. Read the labels carefully.

Many people ask if they
need to restrict milk and milk-containing products because milk contains lactose
(the sugar found in milk) naturally. Many people lack the enzyme lactase, which
is necessary to digest the lactose. If you cannot digest lactose, you will have
gas, diarrhea, and bloating when you consume milk products. However, many people
can tolerate small amounts of milk. For example, you may be able to tolerate
milk on your cereal, even though you cannot drink a glass of milk.

Fiber

You can get fiber
naturally through food (i.e., oatmeal, whole grains, fruits, and vegetables) or
get it through various fiber supplements (see Table 1). Even if your
colon is not connected, you can use fiber to help to thicken up your ostomy
output. This may give you a little more control over your output.

Hydration

Oral rehydration solutions
(ORSs) are used to enhance fluid absorption. These solutions vary widely in
their content (see Table 2). The number and size of the dissolved
particles in a solution determine the osmolality of the solution. The greater
the number of particles and the smaller the size of those particles, the higher
the osmolality. This is expressed as milliosmoles per kilogram of water (mOsm/kg).
The optimal fluid to maximize absorption is isotonic (280 mOsm/kg H2O).
Absorption of fluids is also maximized when the glucose content is 10 g/L, but
even the best solutions have more glucose to increase their palatability.

Of the commercially
prepared ORSs, the World Health Organization’s solution contains the best
mixture of glucose and sodium, and it costs the least. It comes in packets of
powder that can be mixed at home with water and a sugar-free flavoring such as
Kool-Aid or Crystal Light. Other commercially prepared ORSs are available in
over-the-counter premixed bottles and closely approximate the World Health
Organization solution.

Sports drinks, sodas, and
juices contain too much carbohydrate and not enough sodium, and will cause
diarrhea to worsen. In table 2, note the levels of carbohydrate (CHO), sodium
(NA+), and potassium (K+) in the sports drink in comparison to the ORSs.
However, you can add additional water and salt to these drinks to make them more
closely resemble an ORS (see Table 3).

Frequent, Small Meals

As you can see from the
sample menu in table 4, the diet for someone with SBS can be very
palatable, and there are plenty of foods to choose from! Fiber supplements,
along with antidiarrheal medications, can be used as needed to prolong
intestinal transit time.

Supplements

Is It
Okay to Modify the Diet?

Sometimes you just have to
have that favorite food even though you know it is going to run right through
you. Is this okay? Well, on occasion, it is acceptable to sample that favorite
food. But it is best to just “sample” it, and to do it when you are close to a
bathroom. If you do this too often, you are likely to lose too much fluid and
too many electrolytes.

Conclusion

We eat for nutrition as
well as for pleasure. If you have SBS, the type of food you eat and the way you
consume food will affect your absorption. Small adjustments in the diet can give
you more control over your output without you having to sacrifice nutrition or
taste.

Dr.
Matarese is the Director of Nutrition, Intestinal Rehabilitation and
Transplantation Center, Thomas E. Starzl Transplantation Center, University of
Pittsburgh Medical Center, Pittsburgh, Pennsylvania. This article is based on a
presentation Dr. Matarese gave at the Oley Annual Consumer/Clinician Conference
in San Diego in June.

This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

Updated in 2015 with a generous grant from Shire, Inc.

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.